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LOSS OF PASSPORT

  • I )

    DOCUMENTS REQUIRED :

    • ORIGINAL CERTIFICATE OF INSURANCE (PHOTOCOPIES NOT ACCEPTED UNLESS IT IS AN ANNUAL POLICY)

    • AIRLINE TICKETS

    • POLICE REPORT

    • BILLS AND OTHER SUPPORTING DOCUMENTS FOR OBTAINING EMERGENCY TRAVEL DOCUMENT WHILST ABROAD.

1)

Time, Date and Place of Loss

:

2)

Full Circumstances of Loss

:

3)

Name and Position of any other person in authority to whom the matter was reported.

III)

TO

BE

COMPLETED

REPRESENTATIVE.

BY

THE

CLAIMANT

OR

THE

CLAIMANT’S

LEGAL

ADDITIONAL INFORMATION YOU MAY WISH TO GIVE IN SUPPORT OF YOUR CLAIM UNDER ANY SECTION OF THE POLICY

PERSONAL

SPECIAL SETTLEMENTS – U. S. A

Once a claim becomes payable under the terms and conditions of the policy and any costs have been met by you or any person on your behalf please indicate below to whom you would like the cheque be made payable to and their full address :

Payees Name

:

Address

:

When a medical incident has occurred in the USA with total bills not exceeding $500/- in all, the Insured may also post the policy schedule and this fully completed claim form together with the original medical invoices to Coris America, Coris America, 6710,Main Street.Suite#234,Miami lakes, FL 33014., E-mail : corisusa@aol.com , Assistance/Claims Center : Tel :Toll Free(USA) 1 8775367264, Fax 1 305 371 5693. On receipt, Coris will immediately arrange payment either to the Insured or to the Medical Provider. If the claim cannot be paid for any reason (such as incomplete claim form or lack of documentation) or if the claim is for a greater amount than US$ 500/- then Coris will deal with it under the normal settlement procedures in the France.

Toll Free Nos. in U.S.A. 1) 1-877-536-7264 (Within U.S.A)

In case of filing the claim on return to India, the above-referred documents may be posted to Heritage Health Services Pvt. Ltd., 1102, 11th Floor, Raheja Chambers, 213, Free Press Journal Road, Nariman Point, Mumbai – 400 021. The payment of a claim in this manner does not prejudice the Insurer’s right to decline further payments if the claim is subsequently found to be invalid.

TO BE SIGNED BY THE INSURED. I wish my claim, which does not exceed US$ 500/- in all, to be dealt with under the above special arrangement.

SIGNATURE:

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